Hepatic Failure/GI/Endocrine Emergencies

Patient Case

A 27-year-old man with a medical history of Crohn disease presents to your ED with frank bloody output

from his rectum. The patient has hypotension (systolic blood pressure 85 mm Hg, MAP 58 mm Hg), and an

NG lavage reveals “coffee-ground” material. The resident on call is in the process of calling the endoscopy

team to help diagnose and intervene on an UGIB with an esophagogastroduodenoscopy. Which statement is

most accurate regarding the care of this patient?

PPI continuous infusion.

post-endoscopy.

esophagogastroduodenoscopy.

Anticoagulation

Patients who do not have a strong indication for continued anticoagulation at the time of the bleeding

event should have antithrombotic therapy discontinued.

American College of Gastroenterology recommends against the use of fresh frozen plasma or

vitamin K in patients on warfarin hospitalized with GI bleed. Although this group could not reach a

consensus regarding the role of PCC for management of GI bleeding in patients receiving warfarin,

guidelines suggest the use of PCC over FFP, particularly when bleeding is life-threatening, INR is

significantly elevated, or massive blood transfusion is not feasible.

Reversal of dabigatran with idarucizumab is not routinely recommended but may be considered in

patients with a life-threatening GI bleed who have taken dabigatran in the past 24 hours.

hospitalized with a GI bleed.

Administration of PCC for patients hospitalized with GI bleed who have been taking any direct oral

anticoagulant is not routinely recommended. However, use may be considered in patients who have

taken any of these agents in the past 24 hours and have a life-threatening bleed.

Most patients who develop UGIB while receiving long-term antithrombotic therapy continue to be

at risk of thrombosis; these patients should be resumed on antithrombotic therapy.

In a retrospective cohort study of patients who had a GI hemorrhage during warfarin therapy,

those who resumed warfarin within 90 days after the hemorrhagic event had a lower adjusted

risk of death (HR 0.31; 95% CI, 0.15–0.62) and thrombosis (HR 0.05; 95% CI, 0.01–0.58),

without a significant increase in the risk of recurrent GI hemorrhage (HR 1.32; 95% CI, 0.50–

3.57). In this study, warfarin was resumed a median of 4 days (interquartile range 2, 9) after

presentation for UGIB. These data suggest that for many patients with warfarin-associated GI

hemorrhage, the benefits of resuming warfarin therapy outweigh the risks.

ii.

Antithrombotic therapy should be withheld at minimum until the source of bleeding is found

and controlled.

iii.

The patient’s short-term risk of rebleeding should be weighed against the short-term risk of

thrombosis when deciding to resume antithrombotic therapy.

iv.

Some experts recommend that warfarin be resumed 4–7 days after presentation for UGIB.

The risks, benefits, and timing of resuming target-specific oral anticoagulants are unclear.